DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service Commissioned Corps
BOARD CERTIFICATION INCENTIVE PAY (BCIP) AGREEMENT REQUEST
(Privacy Act Notice is on the Second Page)
IDENTIFICATION
NAME (Last, First, Middle Initial)
GRADE/RANK
PHS SERIAL NUMBER ORGANIZATION
DUTY PHONE NUMBER E MAIL
DCCPR USE ONLY
DATE REC’D.
LENGTH OF AGREEMENT REQUESTED (Check box)
I AGREE TO REMAIN ON ACTIVE DUTY IN THE COMMISSIONED CORPS OF THE PUBLIC HEALTH SERVICE (Corps) WITH A
BOARD CERTIFICATION INCENTIVE PAY (BCIP) OBLIGATION FOR: 12 MONTHS
CONDITIONS OF AGREEMENT
In consideration of payment of the BCIP for which I qualify in accordance with 37 U.S.C. 335; Commissioned Corps Directive (CCD)
151.05; and Commissioned Corps Instruction (CCI) 633.01, I hereby agree to the following:
A.
To remain on active duty in the Corps for a minimum period of one year from the following date:
.
I understand
that the effective date of this agreement will be the date determined by procedures set forth by the SG in a Personnel
Operations Memorandum (POM).
B.
That I will be paid BCIP in the amount specified for my category of
with a specialty
in
for a one year active duty obligation after which BCIP will continue on a monthly basis
thereafter provided I continue to meet the eligibility requirements to receive BCIP.
C.
That I hold a current, valid and unrestricted license as directed for my category under CCI 251.01 "Professional Licensure and
Certification" or certification as required by CCI 231.01, "General Appointment Standards." I agree to remain certified in the
specialty referenced in section B, above, during the period I receive BCIP.
D.
That I will receive the BCIP in equal monthly payments.
E.
That if I fail to complete the period of service for which BCIP is paid:
(1) Under the provisions contained in Section 6-7.e. of CCI 633.01, I will be required to refund a pro rata portion of the payment
received which represents the unearned portion of that monthly payment of a terminated agreement in accordance with
37 U.S.C. 373.
(2) Any amount I am obligated to refund because of the termination of this agreement will be a debt due to the United States
which I hereby agree to pay in full as directed by the appropriate collections officials in accordance with CCI 654.02.
(3) That I may not be eligible for recommissioning in the Corps.
F.
If I am not eligible to receive base pay because of a period of Absence Without Leave (AWOL), then I am not eligible for BCIP for
the duration of the AWOL, and I am required to repay the prorated portion of any amount paid during the period of AWOL and my
obligation will be extended for an equal period of time as the AWOL.
G.
Payment of BCIP will normally commence within 90 days after receipt of the completed agreement in DCCPR or within 90 days
after DCCPR receives all necessary supporting documentation.
CERTIFICATION
I certify that I have read and understand CCD 151.05 and CCI 633.01, and I have read and agree to abide by the terms of this BCIP agreement as stated
above and that the above information is true and correct. Further, I understand that making a false statement or claim against the U.S. Government is
punishable by a fine, or imprisonment, or both. 18 U.S.C. § 287; 18 U.S.C. § 1001.
PRINTED NAME
SIGNATURE
DATE
SUPERVISOR CERTIFICATION
I, certify that this officer is eligible to receive this Board Certification Incentive Pay and recommend payment.
PRINTED NAME
TITLE
SIGNATURE
DATE
PHS-7015-1 (Rev. 12/18)
PSC Publishing Services (301) 443-6740
EF
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
